Rates and fees

Monthly medical/dental and vision costs

	Employee only	Employee + child(ren)/domestic partner child(ren)	Employee + spouse/domestic partner	Employee + family
Medical*
GeoBlue CDHP + HSA + Dental	$75.10	$184.84	$209.34	$310.38
GeoBlue PPO + Dental	$153.23	$334.24	$373.39	$556.58
Vision
	$6.97	$13.94	$13.24	$20.49

Fees

Schneider Electric self-insures its medical plan options. This means after you pay your share of the cost for coverage and services, the Company pays the remaining cost of medical claims for you and your family. As a participant in our plans, you have a direct impact on the overall cost of medical expenses. In an effort to help contain these costs, the following fees may apply depending on your responses (or lack of response) during your benefit enrollment:*

Health evaluation non-participation monthly fee: $50 per person
Tobacco-user monthly fee: $50
Working spouse/domestic partner monthly fee: $75

* If you’re a current employee and you don’t change your response during Annual Enrollment, your responses will automatically carry forward to the next calendar year.

Life and AD&D monthly costs

Basic Life Insurance — imputed income

If your Basic Life Insurance coverage is more than $50,000, you will owe taxes on the value of your coverage over $50,000. This value is called imputed income. IRS regulations require the Company to report employee federal wages and deduct Social Security taxes (FICA) on imputed income from your paycheck and report it on your W-2 each year.

Under IRS regulations, imputed income is based on your age and the monthly cost per $1,000 of life insurance over $50,000. To determine your monthly amount of imputed income, multiply the rate in the following IRS table by the amount of your insurance coverage over $50,000 divided by $1,000.

IRS Table — Monthly cost of $1,000 of insurance
Employee’s age	IRS rate
Under 25	$0.05
25 – 29	$0.06
30 – 34	$0.08
35 – 39	$0.09
40 – 44	$0.10
45 – 49	$0.15
50 – 54	$0.23
55 – 59	$0.43
60 – 64	$0.66
65 – 69	$1.27
70 and over	$2.06

Imputed income example

Supplemental AD&D Insurance

The monthly rate for Supplemental AD&D Insurance is $0.019 for every $1,000 of coverage you elect.

Supplemental Life and Spouse Life Insurance

Monthly rate per $1,000 of coverage:

Employee/spouse age	Employee rates		Spouse rates
Employee/spouse age	Non tobacco-user rate	Tobacco-user rate	Non tobacco-user rate	Tobacco-user rate
Under 25	$0.026	$0.039	$0.023	$0.035
25 – 29	$0.031	$0.047	$0.031	$0.046
30 – 34	$0.042	$0.062	$0.039	$0.058
35 – 39	$0.046	$0.074	$0.045	$0.073
40 – 44	$0.049	$0.087	$0.058	$0.100
45 – 49	$0.081	$0.132	$0.095	$0.150
50 – 54	$0.123	$0.203	$0.141	$0.230
55 – 59	$0.217	$0.360	$0.224	$0.400
60 – 64	$0.360	$0.561	$0.383	$0.650
65 – 69	$0.662	$0.985	$0.659	$1.050
70 and over	$1.206	$1.815	$1.566	$2.600

Child Life Insurance

Coverage level	Weekly cost	Semi-monthly cost
$5,000	$0.10	$0.20
$10,000	$0.21	$0.40

Disability monthly costs

Short-term disability

Your options	STD coverage levels	Cost per $100 of monthly base pay
Company-paid	100% of your base pay for 4 weeks, 60% of your base pay thereafter	$0.00
Buy-up^1,²	100% of your base pay for 4 weeks, 70% of your base pay thereafter	$0.035

se-benefitslink.com.

Long-term disability

Your options	LTD coverage levels	Cost per $100 of monthly base pay
Company-paid	50% of your base pay	$0.00
Buy-up²	60% of your base pay	$0.111

Legal services plan

The cost for coverage is $16.50 per month.

1. Due to state law, employees who work in New Jersey will automatically receive the STD Buy-up coverage level Company-paid. If you work in New Jersey, your option will be reflected on se-benefitslink.com.
2. Due to state law, employees who work in New York for less than 17.5 hours per week will receive Company-paid disability coverage.